Interview with Dr. Linda Peeno, Subject of Damaged Care

Chief Counsel Rob Lineberger

March 21st, 2003

As critics and movie fans, it is easy for us to forget the people behind the stories we see on the silver screen. But sometimes a story is so engaging that it piques curiosity about the real life players behind it.

Damaged Care tells the story of Dr. Linda Peeno, an expert on health management organizations and ethics. Her expertise is hard-earned. After working at a handful of HMOs, Dr. Peeno could not remain silent, and began to speak out against the ethical problems she encountered. Needless to say, the corporations were none too happy.

Dr. Peeno has spoken before the House of Representatives Subcommittee on Health and Environment and has testified in over 50 trials as an expert witness for the prosecution. And now she gives the readers of DVD Verdict her insights on how Hollywood distilled her story into two hours.

What was your general impression of the movie Damaged Care?

I am very pleased with the movie. From the beginning, Showtime and Paramount committed from the top down to making a movie that was truthful. They knew it was a tough subject (as I tell groups when I speak: who could imagine doing a drama about "utilization review"?). It could easily have ended up as a "good and evil" caricature that would play on the public's hatred of HMOs without doing justice to the complexity and conflicts that are more fundamental to real health system reform. They also knew, especially the producer, that there would be risks in making a film that didn't have the Hollywood titillations (sex and violence) that make for "entertainment." They brought to the whole project a kind of integrity that impressed me, down to accurately portraying the clothes I wore (instead of dressing me like Erin B.), and the use of quotes and writers who profoundly impacted me (Heschel, Merton and Havel). What movie have you seen lately in which a Jewish theologian, a Catholic monk and an elected official obsessed with morality have prominent play through direct quotes?

To achieve this integrity meant that the writer and producer adhered closely to my own story and struggles, however mundane or "boring" that might be in real life. They focused on the conflicts of personal and professional life; the conflicts with the differences in emerging value systems in medicine; the conflicts between cost and care, to name the big ones. When we first talked about the movie, I was very hesitant to have my private life so publicly revealed. I am by nature reclusive and private, and was always the most unlikely person to have stepped forward anywhere along the way. But then as I thought about it, I realized that we all have our own private, personal struggles, most of which are compelling enough to cause us to see them as justifying our attention rather than some "big" issues about which we think we can doing nothing. Who could have blamed me for just capitulating and "doing my job," when I had real problems with the children, our personal economics, and trying to hold a marriage together? But, this has become a big area of interest to me in ethics: when we turn our backs to these larger economic, social, cultural, political and even global issues, telling ourselves "someone else" will take care of things, then who pushes forward the important issues, values, and visions? We all have excuses for retreating into our own protected little worlds. To me, the movie caught this struggle as much as the specific health care issues.

Consequently, I think there is a timeless element to the movie -- a kind of parable effect to it. I know some in the health management industry have tried to say that it portrays a way in which the industry used to be, not the way it is now. But in truth, I think the movie captures these larger tensions between cost and care that spill over into other areas. Even while the movie was being made, the producer and I had frequent long talks about the ways in which these larger forces of corporatization, profitatization, and dehumanization intrude into every sector of life. I have been deluged by emails, not only with regard to the health care issues, but with individuals telling me that the movie gave them courage to do things in other areas of business or life. That to me is its greatest measure of success.

Was the portrayal of you somewhat accurate, or was the account "Hollywoodized"? In other words, were any events glossed over or artificially dramatized?

When I speak to groups, I tell them that if they have watched the movie they have seen a rare Hollywood phenomenon: unadorned truth without the Hollywood hyperbole. The move is narratively true and, in fact every scene is underplayed, not "Hollywoodized" at all. There are, of course, blending of some characters and scenes as nearly thirteen years is collapsed into a two hour piece. For example, there were four doctors with me at Humana, not two. "Brothers" is a melding of the two places I worked after Humana, because one was merged into the other, so they were similar enough for the purposes of integrity about the issues without adding the confusion of two company names.

I did deny the heart transplant. The nurse's story is real, and she did send me the beautiful letter. Actually, I wrote a piece that was published in the US News and World Report entitled "What is the Value of a Voice?" about her voice machine and my approval of it. That is what Showtime saw that prompted their call to me. As a result of its reprinting in Readers Digest, the nurse "Dawn" saw it, recognized that it must have been her about which I was writing, and wrote me the letter thanking me. My daughter, Bryanna, is a social worker, and focuses on early childhood therapy. I do have an adopted African-American daughter and my two daughters are the love of my life. My relationship with my stepson has grown strained over the years since the divorce, much to my regret and sadness. Doug married the last woman of his series of affairs, and she has rewritten history for him, stripping away all reminders for Doug and Bryan of their past family life. My best friend is indeed Sister Mary (Rodi), who is 83 and still runs circles around me with her energy and drive to change the world. I did have a close friend, "Paul," as portrayed in the movie, although much more complicated. I ran into him after the divorce after having not seen him for years, and I had a brief moment in which I thought we might reconnect, but we had both changed too much. The Chipps case was real, and I have now testified in over 50 cases. Everytime I hear another case, I think that things cannot get any worse and they do.

You could take almost any scene and I can expand it into its own story because it is so underplayed. Even the scenes regarding the threatening phone calls are portrayed as almost civil. In fact, they were far more threatening and ominous, including one that threatened to harm the children. Three days after that call, Bryan had a single car accident caused by something locking up in his engine. We never knew what happened, and fortunately he was not seriously hurt.

There are three blatant "untruths" in the movie:

1. My husband never called me "Pix" -- the pet name they used in the movie. In fact, he never called me any pet name, for he just wasn't that type, at least with me.

2. I have never in my life eaten a Krispy Kreme doughnut, if you recall the scene where my nurse friend wants to escape to K.K.

3. The cost of the sculpture is NOT $488,000, but $3.8 MILLION!!! I had been told while I was at Humana that the piece of sculpture cost about "a half million dollars" which was about the cost of the denied transplant. That did represent my first jolt about the fundamental ethical problem of the system as a whole, for we rationalized not just at Humana, but in the health industry overall (and still do) that we have a "cost crisis" that requires that we "ration" or "allocate resources" and then we siphon off money into myriad non-health care business interests rather than actual care. After the move aired someone called me and provide me with the information to support that the piece that I had seen installed was a Giacometti sculpture that cost $3.8 million dollars -- the cost of EIGHT transplants, not one. But imagine if we had used the actual figure -- what extreme hyperbole Showtime would have been accused of!

Some of your nitpicks I agree with. The "threatening phone call" lacked dramatic impact. I expected a follow-up of some kind. This same problem manifested itself in many ways, such as tipping us off to Doug's infidelity early, and foreshadowing a smear campaign by Humana that never materialized. Therefore the end lacked emphasis. And though Laura Dern and Regina King were fantastic, James LeGros was unlikable.

Your comments about some of the artistic parts of the movie are right on target, and even the producer would probably concur. Some of them are the result of those corporate effects that I alluded to which pervade everything, so even when the original goal was to produce a product with integrity, money issues enter in and exert their influence. I think, too, that everyone was trying to waltz that legal line to keep from giving Humana grounds to file a lawsuit. They threatened Showtime and Paramount for months before the movie was released.

Your comments about Doug and James LeGros are especially on target. Apparently, many people felt that JG was wrong for the part (even after casting), but from what I understand there were other forces at work that trumped those concerns. Ironically, he played Doug more accurately than many realize, especially the scene when he encounters me and "Paul" at the restaurant, and the scene when I receive the letter from the anonymous person. The scene about the letter was completely accurate, including our trip to the woman's house where he finally stopped and admitted to the relationship. The incident in which he encountered me while having lunch was far, far worse in real life. One part that I regret is that there wasn't a way in the story line to show the more positive sides of Doug -- especially since he was the one who encouraged me not to go back into practice when I quite my last corporate job. By that time we were economically OK from his practice and he believed that I had a "mission" to educate doctors and patients about what I had witnessed. I owe my course to him. Unfortunately, I think that changes in medicine took its toll on him eventually and much of his unhappiness was the result of many more things than our changing marriage. Although the were frequent affairs, he is a good doctor, was a good father and a good friend most of the time. In fact, I wish the movie could have emphasized the effects of managed care overall on physicians. While Doug may have resorted to sex as a way of dealing with it, other physicians have resorted to other means -- including leaving medicine entirely -- uncalculated prices we are paying and will continue to pay dearly for in society.

Some of the dramatic (or lack of) effects are probably related to the story and attempts to keep it truthful. The threats behind the phone calls vanished when Doug left -- taking away the power of the threat to make his affairs public. The "smear campaign" continues in its subtle, but viscous attack of me in every deposition I do, in which every detail of my life has been dissected and re-dissected again and again, hoping to intimidate, disparage, or frustrate me into quitting. Those are subtleties that are hard to portray. In some ways the movie has shifted all the tactics behind the closed doors of the deposition process. I actually have a piece I wrote coming out in the summer issue of Creative Nonfiction in which I talk about the dual "oaths" that I have as physician -- one the Hippocratic oath, and then the other that I must take when I testify in the legal cases, which gives defense attorneys unbelievable power to probe into every nook and cranny of my life.

When I first saw the movie in a public screening, I couldn't figure out why I felt so immensely sad. Then I realized that the beginning represents the shattering of all my illusions: about marriage, family, medicine, business, personal friendships, etc. And then the end represents the truthful situation that the work continues, unending. There is NOT a trailer that says: "And as a result of her compelling testimony before Congress, they were moved to radically change the health care system. Her work completed, she returned to the practice of medicine, climbs mountains during her vacations and spends all other spare moments with her granddaughter." Instead the work goes on without apparent resolution -- unlike drama. So the "voice" has to keep speaking, even when I am fatigued with it all, especially with what seems to be overwhelming futility on some days. You think it feels heavy by the time you get to the end of the movie...imagine how it feels when there is no end in sight. But then I get an email from someone who has seen the movie, or a message like yours and I am revived.

Dr. Peeno, thanks so much for taking the time to tell us your thoughts. Is there an internet link that we can direct Verdict readers towards to learn more about the issues portrayed in Damaged Care?

I have a web site, www.lindapeeno.com. Coming soon to the site will be general information about the movie based on questions that I have gotten when I speak and a "study guide" for groups that have used the movie. The movie has been used by medical ethics groups and small groups for discussions about the health system, policy and ethical issues.